Obstructive Sleep Apnea

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Obstructive Sleep Apnea

• Brent A. Senior, MD
• Associate Professor
• Chief, Rhinology, Allergy, and Sinus Surgery
• Otolaryngology/Head and Neck Surgery
• University of North Carolina

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What is OSA?

• Disorder of obstructed breathing occurring during
  sleep
• Apnea cessation of breathing with respiratory
  effort lasting greater than 10s
• Hypopnea
• decreased airflow of gt70
• Any decreased airflow with desaturation lt90
• Total apneas and hypopneas per hour AHI or RDI
  or REI

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What is Significant OSA?

• Uh, I dont know
• Most consider significant sleep apnea to be
  present with an REI gt 15
• 15-25 Mild Apnea
• 26-40 Moderate Apnea
• gt40 Severe Apnea

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Whos Got It?

• NCSDR-1993
• 40 million Americans with chronic sleep disorder
• 20 million with occasional sleep disorder
• SDB (REI gt5) 24 middle aged males
• 9 middle aged females
• OSA gt15/hr 4 middle aged males
• 2 middle aged females
• NEJM 1993 328 1230-35

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Why is it so Important?

• Hypertension
• 25 of hypertensives have OSA (AIgt5)
• Sleep Heart Health Study
• 6000 patients corrected for bmi, neck, EtOH
• Nieto, et al. JAMA 283 (14) 1829-36, April 2000
• SDB (including snoring) and Htn correlate
• 1700 patients
• Bixler, et al Arch IM 160 (15) 2289-95, 2000
• Sleep 1980 3 221-4
• BMJ 1987 294 16-19

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Health Impact

• MI
• REI gt20 independent predictor of MI
• 223 German males with angio confirmed CAD
• Schafer, et al. Cardiology 92(2) 79-84, 1999
• Increased mortality in CAD patients
• 5 y study (Sweden)-62 patients 19 with OSA (RDI
  17)
• OSA mortality 37.5 Non-osa mortality 9.3
• Peker, et al. Am J Resp Crit Care 162 (1) 81-6,
  7/2000

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Health Impact

• CVA
• REI severity is independent predictor of Stroke
• 128 patients (UM)- 75 stroke 53 TIA
• 62.5 with AHI gt10 with stroke vs 12 controls
• Bassetti, C et al. Sleep 22(2) 217-23, 3/1999

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Health Impact

• Death
• AIlt20, at 8y follow-up 4 mortality
• AIgt20, at 8y follow-up 37 mortality
• treatment with trach or CPAP 0 mortality
• Chest 1988 94 9-14
• NCSDR 1993
• 38000 CV deaths related to OSA per year

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Societal Impact
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Societal Impact

• 75 of 75000 screened will be diagnosed with OSA
  (275 million)
• Fragmentation of sleep occurring with SDB
• increased daytime sleepiness, decreased
  intellect, behavioral and personality changes,
  enuresis, sexual dysfunction
• Am J Resp Crit Care Med 1996 153 1328-32

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Societal Impact

• Increased Traffic Accidents
• simulated driving SDB 100x more likely to drive
  off the road
• Acta Otolaryn 1990 110 136ff
• 7x increased risk of auto accidents
• Clin Chest Med 1992 13 427-34

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Societal Impact

• Reaction times
• with OSA equivalent to a normal control who was
  legally intoxicated (ABL gt0.8)
• Powell NB et al. Laryngoscope. 109(10)1648-54,
  1999
• UPPP decreases the number of MVA
• ORL 1991 53 106-111
• Laryngoscope 1995 105 657-61

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Hows it Diagnosed?

• History, Physical Examination, and Sleep Study
• History
• Disrupted sleep, restless sleep, awaken with
  gasping and choking
• Loud snoring
• Tired, inappropriate falling asleep
• Witnessed apneas

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History

• Associated Complaints
• Weight changes
• Thyroid/Growth Hormone abnormalities
• GERD
• Habits
• sleep schedule
• EtOH
• PMH/Meds
• Hypertension
• Sedatives Antihistamines

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Physical Exam

• Height and Weight (BMI)
• BMI703.1 x weight(pounds) / Height (in)2
• neck size
• Face-retrognathia
• Nose
• Oral cavity- palate, uvula, tonsils/pillars,
  tongue, occlusion

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Physical Examination
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Physical Examination
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Fiberoptic Nasopharyngolaryngoscopy

• Determines level of obstruction
• Provides estimate of degree of obstruction
• Technique
• supine (i.e., in a sleeping position)
• at FRC-point of maximal relaxation
• snore maneuver
• Mueller maneuver- inspire against a closed airway

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Evaluation

• Key Features of the History and Exam
• History (105 patients)
• apnea reported by bed partner (plt0.01)
• awakes with choking (plt0.005)
• hypertension dias gt95 (plt0.01)
• Exam
• BMIgt30 (plt0.01)
• All sensitivity 92 specificity 51
• Am Rev Resp Dis 1990 142 14-18

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Objective Sleep Monitoring

• Rationale Difficulty predicting OSA by HP with
  no EDS
• Loud snoring and witnessed apneas identify OSA
  54-64 of the time
• Sleep 1988 11 430-36
• HP predict OSA only 60 of the time
• Sleep 1993 16 118-22

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How To Treat?

• Minimal intervention
• Drop the Weight!
• Dental Appliances
• Variable success rates, though probably more
  useful for mild apnea
• ?compliance
• Interventional
• CPAP
• Surgery

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CPAP

• The Gold Standard in the treatment of OSA
• Works the best in the most people
• Positive pressure ventilation functions as a
  pneumatic splint for the collapsing upper airway
• But... compliance is very poor
• 159/214 (74) mean 5.6 h/night 77-89
  compliance (!)
• Krieger. Sleep 15 (6 Suppl) S42-6, 1992

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Surgery

• Tracheotomy
• An incision in the trachea
• Cures OSA nearly 100 of the time
• Prior to 1980, its all we had still useful for
  severe apneics

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Remove Tissue- Uvulopalatopharyngoplasty(UPPP)

• First successful alternative to tracheotomy
• 12 individuals
• preop AI 54 /- 28
• postop AI 28 /- 28
• 8/12 with post-op AIlt20
• Fujita et al. Otolaryngol HNS 1981 89923-34

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Remove Tissue-Other Surgeries

• Laser Midline Glossectomy
• Palatal Somnoplasty
• LAUP
• Radiofrequency tongue base reduction
• Woodson, et al, AAO 2000, Washington DC
• 18 patients completed protocol, average 15,696 J
• REI decreased from 45.3 to 33.3

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Enlarge the Bony Space-Other Surgeries

• Genioglossus Advancement/ Hyoid Repositioning
• Success 80 (11-18mm)
• Less effective with RDI gt60
• Maxillo-mandibular Advancement
• Particularly useful in the setting of
  hypopharyngeal obstruction (Fujita 2 or 3)
• Best results when performed following Stage 1
  surgery

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Complication Avoidance

• All OSA patients are at risk of Airway
  Obstruction (even mild)
• Minimize risk
• Expect intubation disaster
• Pharyngeal procedure with nasal procedure
  increases risk regardless of apnea severity
• Mickelson and Hakim, Oto HNS 119 352-6, 1998
• Amount of intraoperative narcotic- worse with
  greater apnea severity
• Esclamado, Laryngoscope 99 11-29, 1989
• Monitor post-op with continuous oximetry

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Summary

• OSA is a potentially life-threatening disorder
  that demands proper evaluation
• Components of that proper evaluation include
  detailed sleep history, PE, and endoscopic
  evaluation
• Objective sleep evaluation is required prior to
  intervention

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Summary

• Treatments include
• Conservative non-interventional techniques
• Weight loss, dental appliances
• CPAP
• Surgery